"Ohio Peace Officer Training Commission		APPLICATION FOR A LICENSE TO CARRY A CONCEALED HANDGUN				1493
		Please Type or Print in Ink				1494

SECTION I.				1495
This application will not be processed unless all applicable questions have been answered and until all required supporting documents as described in division (B) or (F) of section 2923.125 of the Ohio Revised Code and, unless waived, a cashier's check, certified check, or money order in the amount of the applicable license fee or license renewal fee have been submitted. FEES ARE NONREFUNDABLE.				1496

Last		First		Middle		1499
................		................		..............		1500

Street	City	State	County	Zip		1503
............	............	............	...........	............		1504

Street	City	State	Zip		1506
............	............	............	..............		1507

Date of Birth		Place of Birth		Sex		Race		Residence Telephone		1508
...../..../....		............		....		.....		(...).........		1509

(1) Have you been a resident of Ohio for at least forty-five days and have you been a resident for thirty days of the county with whose sheriff you are filing this application or of a county adjacent to that county?		.... YES		.... NO		1511
(2) Are you at least twenty-one years of age?		.... YES		.... NO		1512
(3) Are you a fugitive from justice?		.... YES		.... NO		1513
(4) Are you under indictment for a felony, have you ever been convicted of or pleaded guilty to a felony, or have you ever been adjudicated a delinquent child for committing an act that would be a felony if committed by an adult?		.... YES		.... NO		1514
(5) Are you under indictment for or otherwise charged with, or have you ever been convicted of or pleaded guilty to, an offense under Chapter 2925., 3719., or 4729. of the Ohio Revised Code that involves the illegal possession, use, sale, administration, or distribution of or trafficking in a drug of abuse, or have you ever been adjudicated a delinquent child for committing an act that would be an offense of that nature if committed by an adult?		.... YES		.... NO		1515
(6) Are you under indictment for or otherwise charged with, or have you been convicted of or pleaded guilty to within three years of the date of this application, a misdemeanor that is an offense of violence or the offense of possessing a revoked or suspended concealed handgun license, or have you been adjudicated a delinquent child within three years of the date of this application for committing an act that would be a misdemeanor of that nature if committed by an adult?		.... YES		.... NO		1516
(7) Are you under indictment for or otherwise charged with, or have you been convicted of or pleaded guilty to within ten years of the date of this application, resisting arrest, or have you been adjudicated a delinquent child for committing, within ten years of the date of this application an act that if committed by an adult would be the offense of resisting arrest?		.... YES		.... NO		1517
(8)(a) Are you under indictment for or otherwise charged with assault or negligent assault?		.... YES		.... NO		1518
(b) Have you been convicted of, pleaded guilty to, or adjudicated a delinquent child two or more times for committing assault or negligent assault within five years of the date of this application?		.... YES		.... NO		1519
(c) Have you ever been convicted of, pleaded guilty to, or adjudicated a delinquent child for assaulting a peace officer?		.... YES		.... NO		1520
(9)(a)(i) Are you under an adjudication of mental incompetence?		.... YES		.... NO		1521
(ii) Have you ever been involuntarily hospitalized or institutionalized pursuant to a court order?		.... YES		.... NO		1522
(b) If the answer to (9)(a)(ii) is "YES," has a psychiatrist certified that the condition is in remission and is not reasonably likely to redevelop at a future time and that you no longer represent a risk of physical harm to others or has the court order been reversed or vacated?		.... YES		.... NO		1523

	.......................		1546
	Signature of Applicant"		1547